Surgical Education as a Complex Adaptive System: The Need for Pedagogical Competence

Mackenzie R. Cook

doi:10.1016/j.jsurg.2026.104057

Surgical Education as a Complex Adaptive System: The Need for Pedagogical Competence

2026-06-26

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Mackenzie R. Cook *

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Ruchi Thanawala

DOI：10.1016/j.jsurg.2026.104057

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Surgical graduate medical education now unfolds within a health care system undergoing rapid and accelerating transformation. Three forces have substantially reshaped the environment in which surgeons are trained: the shift toward competency-based medical education, the increasing structural complexity of modern health systems, and broad sociotechnological changes affecting clinical practice. Together, these forces have not only altered how surgeons learn but what is required of the faculty responsible for training them, and they have done so against a social, political, financial, and administrative backdrop that has been highly unstable for years. This perspective argues that surgical education is best understood as a complex adaptive system, in which learning emerges from interactions among learners, faculty, interprofessional teams, institutions, and shifting regulatory structures rather than from a stable teacher-learner dyad. Within this environment, effective teaching does not emerge in parallel with clinical expertise, learning opportunities do not arise at the same cadence for all trainees, and the educational alliance is not solely situated within a trainee-supervisor pair. Mere participation in the graduate medical education process remains essential but is no longer sufficient. What contemporary surgical faculty require is pedagogical competence: the ability to sustain dialogue-based educational alliances, calibrate progressive responsibility through defensible and dynamic entrustment decisions, intentionally create learning opportunities within complex clinical microsystems, and deliver assessments that support reflective practice and professional growth. When faculty lack preparation for these responsibilities, the validity of competency-based assessment is compromised, and the integrity of entrustment decisions is threatened. Sustained improvement demands structural reform. Pedagogical competence must be recognized as a core professional expectation, educational roles concentrated among faculty who actively develop teaching expertise, and teaching evaluated by patterns of learner development rather than participation alone.

Surgical Education as a Complex Adaptive System: The Need for Pedagogical Competence

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